Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services

Under Hospital Insurance

Table of Contents

Crosswalk to Old Manual

10 - Requirements - General

10.1 - Medicare SNF PPS Overview

10.2 - Medicare SNF Coverage Guidelines Under PPS

10.3 - Hospital Providers of Extended Care Services

20 - Prior Hospitalization and Transfer Requirements

20.1 - Three-Day Prior Hospitalization

20.1.1 - Three-Day Prior Hospitalization - Foreign Hospital

20.2 - Thirty-Day Transfer

20.2.1 - General

20.2.2 - Medical Appropriateness Exception

20.2.2.1 - Medical Needs Are Predictable

20.2.2.2 - Medical Needs Are Not Predictable

20.2.2.3 - SNF Stay Prior to Beginning of Deferred Covered Treatment

20.2.2.4 - Effect of Delay in Initiation of Deferred Care

20.2.2.5 - Effect on Spell of Illness

20.2.3 - Readmission to a SNF

20.3 Payment Bans

20.3.1 - Payment Bans on New Admissions

20.3.1.1 - Beneficiary Notification

20.3.1.2 - Readmissions and Transfers

20.3.1.3 - Sanctions Lifted: Procedures for Beneficiaries Admitted During the Sanction Period

20.3.1.4 - Payment Under Part B During a Payment Ban on New Admissions

http://www.cms.hhs.gov/manuals/102_policy/bp102c08crosswalk.pdf

20.3.1.5 - Impact of Consolidated Billing Requirements

20.3.1.6 - Impact on Spell of Illness

30 - Skilled Nursing Facility Level of Care - General

30.1 Administrative Presumption

30.2 - Skilled Nursing and Skilled Rehabilitation Services

30.2.1 - Skilled Services Defined

30.2.2 - Principles for Determining Whether a Service is Skilled

30.2.3 - Specific Examples of Some Skilled Nursing or Skilled Rehabilitation Services

30.2.3.1 - Management and Evaluation of a Patient Care Plan

30.2.3.2 - Observation and Assessment of Patients Condition

30.2.3.3 - Teaching and Training Activities

30.2.4 - Questionable Situations

30.3 - Direct Skilled Nursing Services to Patients

30.4. - Direct Skilled Rehabilitation Services to Patients

30.4.1 Skilled Physical Therapy

30.4.1.1 - General

30.4.1.2 - Application of Guidelines

30.4.2 - Speech Pathology

30.4.3 - Occupational Therapy

30.5 - Nonskilled Supportive or Personal Care Services

30.6 - Daily Skilled Services Defined

30.7 - Services Provided on an Inpatient Basis as a Practical Matter

30.7.1 - The Availability of Alternative Facilities or Services

30.7.2 - Whether Available Alternatives Are More Economical in the Individual Case

30.7.3 - Whether the Patients Physical Condition Would Permit Utilization of an Available, More Economical Care Alternative

40 - Physician Certification and Recertification

50 - Covered Extended Care Services

50.1 - Nursing Care Provided by or Under the Supervision of a Registered Professional Nurse

50.2 - Bed and Board in Semi-Private Accommodations Furnished in Connection With Nursing Care

50.3 - Physical, Speech, and Occupational Therapy Furnished by the Skilled Nursing Facility or by Others Under Arrangements With the Facility and Under Its Supervision

50.4 - Medical Social Services to Meet the Patients Medically Related Social Needs

50.5 - Drugs and Biologicals

50.6 - Supplies, Appliances, and Equipment

50.7 - Medical Service of an Intern or Resident-in-Training

50.8 - Other Services

50.8.1 - General

50.8.2 - Respiratory Therapy

60 - Covered Extended Care Days

70 - Medical and Other Health Services Furnished to SNF Patients

70.1 - Diagnostic Services and Radiological Therapy

70.2 - Ambulance Service

70.3 - Inpatient Physical Therapy, Occupational Therapy, and Speech Pathology Services

70.4 - Services Furnished Under Arrangements With Providers

10 - Requirements - General

(Rev. 1, 10-01-03)

A3-3130, SNF-210, A-01-122, A-02-096, A-00-49 - 8/00, 1861 of the Act

The term extended care services means the following items and services furnished to an inpatient of a skilled nursing facility (SNF) and by the skilled nursing facility either directly or under arrangements as noted in the list below:

Nursing care provided by or under the supervision of a registered professional nurse;

Bed and board in connection with furnishing of such nursing care;

Physical or occupational therapy and/or speech-language pathology services furnished by the skilled nursing facility or by others under arrangements with them made by the facility;

Medical social services;

Such drugs, biologicals, supplies, appliances, and equipment, furnished for use in the skilled nursing facility, as are ordinarily furnished by such facility for the care and treatment of inpatients;

Medical services provided by an intern or resident-in-training of a hospital with which the facility has in effect a transfer agreement (see 50.7) under an approved teaching program of the hospital, and other diagnostic or therapeutic services provided by a hospital with which the facility has such an agreement in effect, and

Other services necessary to the health of the patients as are generally provided by skilled nursing facilities, or by others under arrangements.

Post-hospital extended care services furnished to inpatients of a SNF or a swing bed hospital (see 2230 of Pub. 15-1 , the Medicare Provider Reimbursement Manual, Part 1) are covered under the hospital insurance program. The beneficiary must have been an inpatient of a hospital for a medically necessary stay of at least three consecutive calendar days. In addition, the beneficiary must have been transferred to a participating SNF within 30 days after discharge from the hospital, unless the exception in 20.2.2 applies.

To be covered, the extended care services must be needed for a condition which was treated during the patients qualifying hospital stay, or for a condition which arose while in the provider for treatment of a condition for which the beneficiary was previously treated in a hospital.

The CMS will cover SNF care for beneficiaries involuntarily disenrolling from Medicare+Choice (M+C) plans as a result of a M+C plan termination when they do not have a 3-day hospital stay before SNF admission.

10.1 - Medicare SNF PPS Overview

(Rev. 1, 10-01-03)

A3-3130, SNF-210, A-01-122, A-02-096, A-00-49 - 8/00, 1861 of the Act

Section 1888(e) of the Balanced Budget Act of 1997 (BBA) provides the basis for the establishment of the per diem Federal payment rates applied under PPS to SNFs that received their first payment from Medicare on or after October 1, 1995. A transition period applied for those SNFs that first accepted payment under the Medicare program prior to October 1, 1995. The BBA sets forth the formula for establishing the rates as well as the data on which they are based. In addition, this section prescribes adjustments to such rates based on geographic variation and case mix and the methodology for updating the rates in future years. For the initial period of the PPS beginning on July 1, 1998, and ending on September 30, 1999, all payment rates and associated rules were published in the Federal Register on May 12, 1998 (63 FR 26252). For each succeeding fiscal year, the rates are to be published in the Federal Register before August 1 of the year preceding the affected fiscal year.

At the inception of the SNF PPS, providers that were enrolled in the Multi-State Case Mix and Quality Demonstration had the option of remaining in the demonstration until the end of their current fiscal year. Providers with fiscal years that ended by June 30, 1998 converted to PPS payment on the first day of their fiscal year beginning with the cost reporting year July 1, 1998, with all providers having transitioned by June 30, 1999.

The Federal rate incorporates adjustments to account for facility case mix using Resource Utilization Groups Version III (RUG-III), the patient classification system used under the national PPS. RUG-III, is a 44-group patient classification system that provides the basis for the case-mix payment indices (or relative payment weights) used both for standardization of the Federal rates and subsequently to establish case-mix adjustments to the rates for patients with different service use. A case-mix adjusted payment system measures the intensity of care (e.g., hours of nursing or therapy time needed per day) and services required (i.e., requirement of a ventilator) for each resident and then translates it into a specific payment level. Information from the most recent version of the Resident Assessment Instrument version 2.0 is used by SNFs to classify residents into one of 44 RUG-III groups. SNFs complete these assessments according to an assessment schedule specifically designed for Medicare payment.

For Medicare billing purposes, there is a payment code associated with each of the 44 RUG-III groups, and each assessment applies to specific days within a residents SNF stay. SNFs that fail to perform assessments timely are paid a default payment for the days of a patients care for which they are not in compliance with this schedule. Facilities will send each beneficiarys MDS assessment to the State and claims for Medicare payment to the intermediary on a 30-day cycle.

http://www.cms.hhs.gov/regulations/

10.2 - Medicare SNF Coverage Guidelines Under PPS

(Rev. 1, 10-01-03)

PM - A-98-16 dated 5/98

Under SNF PPS, covered SNF services include post-hospital SNF services for which benefits are provided under Part A (the hospital insurance pr